Women who have had a hysterectomy should have continuous oestrogens
without progestogens and thus treatment should be straightforward without
bleeding and without PMS type symptoms produced by gestogens which often
limit the acceptability of HRT. However, these women may need a
higher dose than is usual for the vasomotor symptoms and as the surgery
usually occurs in premenopausal women they may well, like those with
a premature menopause need oestrogens for a longer duration for relief
of symptoms.

If the ovaries have been removed these women would have lost their ovarian
androgens and be at risk of developing the Female Androgen Deficiency
Syndrome (FADS) characterised by loss of energy, loss of libido, depression,
loss of self-confidence and headaches. (32) These are frequent
complaints in women who have had a hysterectomy with loss of ovaries
and have been receiving a low dose of oestrogens over the years. These
symptoms can usually be eradicated by the addition of testosterone, either
in the form of implants (licensed for women in many countries) or Testogel,
which although effective will have to be used off-licence in women using
about one quarter of the dose recommended for men. However, the
fact that it is not licensed in a particular country is not a good reason
to deny women this important item of treatment. It should not be
forgotten that testosterone is not only a normal female hormone but it
is present in higher concentrations in young women than oestradiol.

Estradiol and testosterone implants are the most effective and convenient
route of administration for these women with the pellets inserted into
the wound on closure and repeated approximately every 6 months as a simple
office procedure (15). The fact that it is an old drug lacking in patent
or profit or the benefit of costly licensing studies does not reduce
its value in hysterectomised women or those with problems of loss of
energy and libido or depression.
Peri Menopausal Depression

There are many patients in their forties with severe recurrent depression,
sometimes cyclical, who will respond well to transdermal oestrogens. These
patients with reproductive depression often reveal the changes of mood
with changes in hormone levels because of a past history of post natal
depression, premenopausal depression as well as the severe depression
in the peri-menopausal years of the transition. Often they state that
they were last well during the last pregnancy many years ago. They then
developed post natal depression which became cyclical as premenstrual
dysphonic disorder (PMDD) when the periods returned having only about
10 good days per month free of PMS periods and menstrual headaches. The
depression then becomes less cyclical and more constant. (33)

These peri-menopausal women respond well to moderately high doses of
transdermal oestrogens (either moderately high doses 100µg-200µg)
which not only suppress any residual cycle but have a mood elevating
effect. As these women with hormone responsive depression are often
progestogen intolerant, the continuous oestradiol treatment should be
supplemented with progestogen tablets for 7 days of each calendar month
rather than the orthodox 14 days. A Mirena IUS is also useful preventing
the recurrent depression that often occurs with progestogen

Oestrogens do not convincingly help the depression of post menopausal
women apart from the domino effect of removing night sweats/insomnia
or vaginal atrophy and sexual dysfunction. It seems to have little significant
effect in the absence of these classical menopausal symptoms.